=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790388288
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MONICA MCBRYDE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2020
-----------------------------------------------------
Last Update Date | 01/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3100 MACCORKLE AVE SE
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25304-1223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-351-1500
-----------------------------------------------------
Fax | 304-351-1510
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 WEATHERIDGE DR
-----------------------------------------------------
City | HURRICANE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25526-8743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-412-3214
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 105549
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------